Self-system and mental health status among Malaysian youth attending higher educational institutions: A nationwide cross-sectional study

Abstract Introduction: Mental health disorders (MHDs) are a global health burden with an increasing prevalence. During the COVID-19 pandemic, depression was the commonest MHD, followed by anxiety and stress. This nationwide study aimed to determine the prevalence and associated factors of depression, anxiety and stress among Malaysian students attending higher educational institutions. Methods: A cross-sectional study was conducted from June to December 2021. Institutions were selected via stratified random sampling and students via convenience sampling. A self-administered questionnaire comprising questions on socio-demographic characteristics, academic background, substance abuse, childhood abuse, religiosity and the Depression Anxiety Stress Scale-21 was used. Data were analysed using SPSS version 27; descriptive, point-biserial correlation, chi-square and multiple binary logistic regression analyses were conducted. Results: Sex and adverse childhood experiences significantly predicted all three MHDs (P<0.05). The students from public institutions (odds ratio [OR]=0.71, 95% confidence interval [CI]=0.56—0.90, P=0.004) had a lower risk of depression than those from private institutions. The smokers/vapers (OR=1.43, 95% CI=1.02–2.02, P=0.041) a higher risk of depression than the non-smokers/non-vapers. The social science students (OR=1.29, 95% CI= 1.01–1.65, P=0.039) had a higher risk of anxiety than the science students. The students who highly engaged in organisational religious activity (OR=0.91, 95% CI=0.84–0.98, P=0.015) had a lower risk of anxiety than their counterparts. Conclusion: Anxiety is the commonest MHD among Malaysian youth, followed by depression and stress. Childhood abuse is a crucial related factor requiring further attention. Screening, surveillance, preventive measures and comprehensive interventions for MHDs should be initiated among youth.


Introduction
Mental health disorders (MHDs) are a signi cant global concern with an alarming prevalence.According to the World Health Organization (WHO), MHDs account for 13% of the global burden of health diseases among individuals aged 10-19 years. 1 In Malaysia, university students have shown a high prevalence of depression (up to 31%), anxiety (up to 60%) and stress (up to 26%). 2,3 local study demonstrated a substantial increase in these numbers during the COVID-19 pandemic: 59.2%, 55.1% and 30.6%, respectively. 4evious studies conducted worldwide have shown that psychological distress originates from multiple factors.][6][7][8][9][10][11][12][13] Additionally, individual factors such as religiosity 13 and history of adverse childhood experiences (ACEs), including childhood sexual abuse, physical abuse, emotional abuse and neglect, can signi cantly impact an individual's mental health status in the long term. 14,15A study conducted among a multi-ethnic Asian population has revealed that religiosity, regardless of the speci c religion, plays a crucial role in maintaining positive mental health compared with no religion. 16is nding corroborates that of a study conducted locally. 13According to the WHO, any type of ACE is linked to a 44% increase in the risk of various health conditions in adulthood, including mental illness. 17In Malaysia, a similar nding has been reported, wherein about 23% of individuals with a history of ACEs indicated experiencing depression. 18 the best of our knowledge, no study has yet been conducted nationwide in this area, particularly among Malaysian youth attending higher educational institutions.is limitation hinders the generalisation of ndings.Notably, these stressors may have di erent e ects on di erent population groups.Understanding these di erences is essential for crafting targeted and e ective intervention strategies tailored to the local context, particularly during challenging circumstances such as a pandemic.
erefore, this study aimed to investigate the prevalence of MHDs and the association with selfsystem factors, including socio-demographic characteristics, ACEs and religiosity, among Malaysian youth attending higher educational institutions.We hypothesised that there is a high prevalence of MHDs among Malaysian youth attending higher educational institutions, and there is an association between selfsystem factors and MHDs.We utilised the psychodynamic theory by Sigmund Freud as the foundational framework in understanding the association between self-system and psychological distress. 19 ndings of this study are expected to serve as baseline data for future researchers and relevant authorities towards formulating e ective mental health strategies and preventive e orts, with a particular emphasis on self-system.

Study design and setting
is quantitative, nationwide cross-sectional study investigated Malaysian youth attending local higher education institutions.Data were collected from June to December 2021.

Study population
We recruited students attending higher educational institutions in Malaysia.In particular, Malaysian citizens who were aged 18-24 years and able to understand either the Malay or English language were included.Malaysian citizens who were diagnosed with psychiatric illness were excluded to avoid bias in answering the Depression Anxiety Stress Scale-21 (DASS-21); the tool is meant for screening mental illness.

Sample size calculation
e sample size was calculated using the singleproportion formula.In a previous study, the prevalence of depression, anxiety and stress was 59.2%, 55.1% and 30.6%, respectively. 4With the signi cance level set at 0.05 and considering an 80% non-response rate for online surveys, the minimum sample size was calculated as 686 participants.

Sampling method
Two-stage sampling was conducted, with strati ed random sampling applied to select institutions and convenience sampling to select students.Strati ed sampling was employed to enhance the generalisability of the study to encompass the entire Malaysian tertiary highereducation student population.
is approach ensured that each stratum was adequately represented, maintaining proportions accurately.Malaysia was divided into Peninsular Malaysia and East Malaysia, and Peninsular Malaysia was further divided into ve regions.Gatekeepers from each selected institution shared the survey link through their o cial WhatsApp groups as well as o cial institution emails, and willing students responded to the survey.e number of samples in each region was calculated in proportion to the region's distribution of students.A total of 32 institutions were selected and approached, but only 25 universities agreed to participate in this study.

Study instrument
A self-administered online questionnaire, which was available in Malay and English, was used.
e rst section consisted of questions on selfsystem factors including socio-demographic characteristics, academic background, substance abuse, ACEs and religiosity.ere were four dichotomous questions for ACEs: childhood sexual abuse, physical abuse, emotional abuse and neglect. is scale had an acceptable level of internal consistency, with a Cronbach's alpha value of 0.61.Face validity was tested to check whether the instrument measures what it is supposed to measure.e total score ranges from 0 to 4. Higher scores re ect multiple involvement in ACEs.
e Duke University Religion Index (DUREL) was used to measure the degree to which the participants were involved with religion. 20 e Malay-translated version (DUREL-M) also has good internal reliability of 0.8. 21It is a Likert scale that consists of ve items and measures three dimensions, namely organisational religious activity (ORA), non-organisational religious activity (NORA) and intrinsic religiosity (IR).ORA refers to religious activities performed in a formal and public setting; NORA refers to religious activities performed privately; and IR refers to performing religious activities as an ultimate end. 22e total score ranges from 5 to 27.Higher scores re ect a high degree of religiosity.
e second section of the questionnaire was the DASS-21.
e scale is a validated selfreported screening tool used to assess three domains, namely depression, anxiety and stress.
e depression domain measures feelings of hopelessness, devaluation of life, anhedonia and lack of interest.
e anxiety domain assesses autonomic arousal, skeletal muscle e ects, situational anxiety and the presence of anxious feelings.
e DASS-21 has high reliability scores, with a Cronbach's alpha value of 0.91 for the depression domain, 0.84 for the anxiety domain and 0.90 for the stress domain. 23e Malay version of the DASS-21 was adapted from a previous study.is version also has good Cronbach's alpha values of 0.84 for the depression domain, 0.74 for the anxiety domain and 0.79 for the stress domain. 24It uses a 4-point Likert scale, and each domain consists of seven questions. e sum score is calculated separately for each domain.e total score is multiplied by two and categorised into normal, mild, moderate, severe and extremely severe.In this study, the scores were dichotomised into normal and abnormal (mild to extremely severe).e cut-o scores for normal were ≤9 for depression, ≤7 for anxiety and ≤14 for stress.

Data collection
Students were approached by gatekeepers from each institution.e gatekeepers were members of the Student Representative Council and Student A airs Department.A link to the informed consent form was given via email and WhatsApp, and students who met the inclusion criteria were provided a subsequent link to the questionnaire.
e survey was conducted anonymously and con dentially, encouraging honest responses and reducing social desirability bias to ensure genuine responses without the fear of being criticised or judged.

Data analysis
Data were managed and analysed using SPSS version 27 (IBM, Chicago, IL).
ey were cleaned to detect missing values, coding errors or illogical values.Descriptive statistics were computed for all variables.Categorical data were reported as frequencies and percentages and continuous data as means and standard deviations (SDs).e association between the variables was evaluated using chi-square analysis, and the predictors of depression, anxiety and stress were determined using multiple binary logistic regression analysis.e signi cance level was set at P<0.05.

Ethical approval Ethical approval was obtained from the Medical Research and Ethics Committee for Research
Involving Human Subjects at Universiti Putra Malaysia (approval ID: JKEUPM-2021-141).
e data obtained were kept con dential and will be destroyed after 5 years.e respondents who scored severe or extremely severe levels in the DASS-21 domains were contacted for further assessment when they consented.

Results
A total of 1211 students from public and private higher educational institutions (universities and university colleges) across Malaysia responded to the online survey.Of them, 40 (3%) did not ful l the inclusion criteria: Eight refused to participate further in this study; ve were currently under follow-up for psychiatric illness; 25 were not from the selected institutions (non-short-listed institutions -the questionnaire link could have been shared by the target respondents); and two respondents had incomplete data, all of whom were thus excluded.e nal useable data were obtained from 1171 students, and the total response rate was 99.3%.

Participant characteristics
e mean age of the participants was 20.16 (SD 1.66) years.More than half of the participants were aged 18-20 years (60.3%, n=706), suggesting that most of them were transitioning into adulthood and thus facing unique challenges and stressors.Most participants were women (70%, n=820), raising the possibility of a potentially higher prevalence of MHDs, as women are often recognised as being more vulnerable to certain stressors than men.Almost two-thirds of the participants were Malays and Muslims (66.5%, n=779), providing a cultural context that could in uence the outcomes.Most participants (89.2%, n=1044) stayed with their families during the data collection, which may indicate that most students had a strong support system.Over half of the participants lived in urban areas (65.8%, n=770).Only 0.3% (n=3) were married, and a small proportion (15.6%, n=183) reported that their parents were either divorced/separated or widowed.Over half (58.5%, n=685) reported that they came from the below 40% group with a household income of RM 4849 and below.Approximately 15.5% had a smoking or vaping history; 17.8% consumed alcohol; and 0.9% admitted to having a history of drug abuse.ese factors may have contributed signi cantly to the mental health burden experienced by the participants.
e socio-demographic characteristics are summarised in Table 1 Academic background Among the respondents, the majority (45.3%, n=531) were rst-year students, and only a small proportion (9.0%, n=105) were in their nal year.A larger proportion of the respondents were social science students, and only 38.3% (n=449) were science students.e distribution of the respondents studying at private and public universities/colleges was almost equal: 50.3%, n=589 vs 49.7%, n=582.
ese ndings indicated that most students were in their adjustment period to university life, varying in academic background, stressor and exposure to science-related knowledge.

ACEs
e mean number of ACEs among the respondents was relatively low (0.22, SD=0.614).Approximately 2.7% experienced childhood sexual abuse; 4.3%, physical abuse; 11.3%, emotional abuse; and 4.3%, neglect.e existence of these ACEs, even among a small proportion of the participants, could result in enduring adverse e ects on the mental health of these individuals during their adulthood.

Religiosity
e religiosity varied between the three types, namely ORA, NORA and IR; the means and SDs were 4.82 (1.57), 4.24 (1.96) and 12.73 (3.23), respectively.is variation in religiosity may play role in shaping the participants' belief systems and engagement with religion, which could in uence their mental health outcomes.

Associated factors of depression, anxiety and stress
Table 3 shows the inferential analysis of the factors associated with depression, anxiety and stress.Sex, parents' marital status and ACEs were signi cantly associated with depression, anxiety and stress (P<0.05).Conversely, the type of institution, eld of study and three types of religiosity were signi cantly associated only with depression and anxiety.A history of smoking and vaping was signi cantly associated with depression alone and age with anxiety alone.e variables that were signi cant (P<0.05) in the bivariate analysis were further analysed and included in the multiple binary logistic regression analysis.

Predictive model for depression, anxiety and stress
Multiple logistic regression analysis was conducted to determine the predictors of depression, anxiety and stress, and the ndings are shown in Table 4. Sex and ACEs signi cantly predicted the development of depression, anxiety and stress.e female students had a 1.59, 1.45 and 2.12 times higher risk of depressive, anxiety and stress symptoms, respectively, than the male students.e risk of depressive symptoms among the students who had a history of smoking or vaping was 1.43 times higher than that among the students who had no such history.Two other predictors of the development of anxiety symptoms were identi ed: eld of study and ORA. e social science students were 1.29 times more likely to have anxiety symptoms than the science students.In terms of religiosity, only high participation in ORA was found to be signi cant as a protective factor against anxiety symptoms (adjusted odds ratio=0.91,P=0.005) during the COVID-19 pandemic.Conversely, the students studying at public universities were 0.71 less likely to have depressive symptoms than those studying at private universities.

Discussion
is study aimed to determine the prevalence of MHDs among Malaysian youth and the factors contributing to these conditions.e present ndings corroborate previous reports among university students in the United States and in Selangor during the pandemic, where the majority of university students reported experiencing moderate-to-extremely severe levels of anxiety symptoms. 25,26Both studies reported a high prevalence of psychological distress, with more than 50% exceeding clinical cut-o points.However, a prior study conducted before the pandemic showed a lower prevalence of psychological distress among university students, with only 21% reporting depression, 50% experiencing anxiety and 12% reporting stress. 27Such disparities in the reported prevalence could be attributed to the impact of COVID-19 and di erent phases of the outbreak.
e signi cant rise during the earlier phase of the COVID-19 pandemic could be attributed to overwhelming feelings during the lockdown, as students were con ned at home and had to adjust their lifestyles considerably.In contrast, the changes during the later phases could be attributed to an accumulation of apprehensive feelings stemming from the beginning of the outbreak, negatively a ecting the quality of life.However, all previous studies have shared a common similarity wherein women reported higher levels of moderate-to-extremely severe mental health issues, as also noted in this study.Women tend to cope with psychological distress through rumination, constantly thinking about unpleasant emotions and the reason behind those emotions. 28is prolonged exposure to negative emotions may eventually contribute to a greater likelihood of female students experiencing psychological distress than male students particularly during the outbreak.
Herein, the students studying at public institutions were less likely to experience depressive symptoms than those studying at private institutions.is contradicts previous reports that students studying at public institutions are more prone to depression owing to the burden of heavier academic assignments and often coming from lowerincome households. 29Conversely, students studying at private institutions face signi cant psychological distress, attributed to factors such as online classes, high tuition fees and extended semesters incurring additional fees. 12se challenges could have had a more pronounced impact on students during the pandemic, potentially deteriorating their mental health.Additionally, our study found that the social science students were more prone to experiencing anxiety than the science students.
is nding may be explained by that of a study conducted in Jordan, which con rmed that science students possessed a higher degree of knowledge and exposure to general information related to the pandemic and were more likely to outsource information from reliable scienti c sources. 10 erefore, science students may have better understood what to expect during the pandemic and been better able to regulate themselves.
A history of abusive childhood experiences and engagement in substance abuse showed an association with psychological distress in this study.
e adverse long-term e ects of unpleasant childhood events may persist into adulthood owing to the traumatic, toxic and stressful experiences during their most vulnerable period of life.e accumulation of these negative emotions may permanently alter brain development, resulting in poor mental health. 15Moreover, students who have experienced multiple childhood adversities are more likely to develop mental health problems than those who have experienced fewer or no adversities. 14Similarly, nicotine in cigarette/ e-cigarette could alter brain functioning by elevating mood through the release of dopamine (positive hormone).However, this unnatural release of dopamine temporarily relaxes users while reducing the brain's capacity to produce dopamine naturally. 30s could result in them smoking more for the pleasing e ect and in a greater dependency on nicotine, increasing the likelihood of severe depression and stress. 8Nevertheless, our study found no association between smoking and anxiety levels, which corroborates previous evidence. 8ncerning religiosity, the students who engaged in ORA were less likely to experience anxiety.However, this nding contradicts a previous report among adults in Selangor, in which there is no association between anxiety and ORA. 31 Students participating in ORA are more likely to participate in public religious activities, giving them opportunities to interact with religious communities.
is exposure may motivate individuals to become more consistent in religious practice, potentially easing anxiety symptoms. 13

Strengths
is study was a nationwide study that investigated the prevalence of depression, anxiety and stress among youth in Malaysia, providing insights into the national prevalence among the population.In addition to the socio-demographic characteristics, the study identi ed other factors that have not been previously explored such as religiosity.

Limitations and recommendations
e main limitation of this study is that the data were collected from students selected using non-probability convenience sampling, limiting the external validity.e survey link was distributed via WhatsApp, leading to its unintended circulation among individuals who were not part of the intended target sample.However, we addressed this issue by subsequently removing these cases from our dataset.Additionally, the online data collection limited the direct contact between the respondents and researchers, which could have hindered the respondents from seeking clari cations about the questionnaire.Nevertheless, the online questionnaire enabled the exploration of sensitive issues, such as child abuse, and minimised the risk of disease transmission during the COVID-19 pandemic.Future researchers are recommended to employ probability sampling and conduct face-to-face data collection wherein researchers are readily available for inquiries.

Conclusion
Anxiety is the most common MHD among Malaysian youth attending higher educational institutions.ere is a considerable increase in the prevalence compared with prior reports.Sex is signi cantly associated with depression, anxiety and stress, while smoking/vaping history is the only signi cant predictor of depression.
e academic background or institution is signi cantly associated with depression, whereas the eld of study is How does this paper make a di erence in general practice?signi cantly associated with anxiety.e presence of ACEs is related to higher risks of depression, anxiety and stress, while involvement in ORA is associated with a lower risk of anxiety.

• e ndings could
serve as baseline data on the prevalence of depression, anxiety and stress and the associated factors among Malaysian youth.• e study highlights that the current leading mental health disorder among Malaysian youth is anxiety.• Sex and adverse childhood experiences are the most signi cant predictors of mental health disorders among Malaysian youth.ssmph.2021.1007748. El-Sherbiny NA, Elsary AY.Smoking and nicotine dependence in relation to depression, anxiety, and stress in Egyptian adults: a cross-sectional study.J Fam Community Med.2022;29(1):8-16.doi:10.4103/jfcm.jfcm_290_21

Table 2 .
Prevalence of depressive, anxiety and stress symptoms among the Malaysian youth attending higher educational institutions (N=1171).

Table 3 .
Associated factors (self-system) of the mental health status among the Malaysian youth attending higher educational institutions (N=1171).
*Signi cant (P<0.05);B, regression coe cient; SE, standard error; AOR, adjusted odds ratio; CI, con dence interval.All assumptions were met.Neither extreme outliers nor multicollinearity was present.e goodness-of-t of the model was checked using the omnibus test of model coe cients.